Pediatrics: Arrhythmias and Bradycardia

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Questions and Answers

Whenever a child has an abnormal heart rate or rhythm, what must you quickly determine?

Determine if the arrhythmia is causing hemodynamic instability or other signs of deterioration.

What are the signs of instability in a patient with arrhythmias? (Select all that apply)

Sudden collapse (correct)

Chest pain or vague discomfort in older children (correct)

Respiratory distress or failure (correct)

Irritability or decreased level of consciousness (correct)

Shock with poor end-organ perfusion (correct)

What are the priorities in initially managing arrhythmias?

The same as they are for all critically ill children: Support ABC and treat underlying cause.

What is bradycardia?

A heart rate that is slow in comparison with a normal heart rate range for the child's age, level of activity and clinical condition. Signup and view all the answers

What is the leading cause of symptomatic bradycardia in children?

Tissue hypoxia. Signup and view all the answers

What is symptomatic bradycardia?

Heart rate below 60/min associated with cardiopulmonary compromise. Signup and view all the answers

What constitutes cardiopulmonary compromise?

Hypotension, acutely altered mental status, signs of shock. Signup and view all the answers

Bradycardia is an ominous sign of?

Sign of impending cardiac arrest in infants and children, especially if hypotension or poor tissue perfusion is present. Signup and view all the answers

What treatment should be considered for children with severe cardiovascular compromise from pulmonary embolism?

Fibrinolytic agents. Signup and view all the answers

What is the initial treatment of pediatric bradycardia with cardiopulmonary compromise?

Bag mask ventilation with 100% O2. Signup and view all the answers

What are the ECG characteristics of bradycardia? (Select all that apply)

QRS complex narrow or wide Signup and view all the answers

When is sinus bradycardia often present?

Often present in healthy children at rest when metabolic demands of the body are low (during sleep). Signup and view all the answers

Why do well-conditioned athletes often have sinus bradycardia?

They have high stroke volume and increased vagal tone. Signup and view all the answers

What can sinus bradycardia develop in response to?

Hypoxia, hypotension, and acidosis. Signup and view all the answers

What is chest compression fraction?

Proportion of the time that compressions are performed. Signup and view all the answers

What medication is indicated for symptomatic bradycardia that persists despite effective oxygenation and ventilation?

Epinephrine. Signup and view all the answers

When should atropine be given before epinephrine?

Give atropine instead of epi for bradycardia caused by increased vagal tone, cholinergic drug toxicity, or complete AV block. Signup and view all the answers

When is atropine preferred over epinephrine?

As the first choice treatment of symptomatic AV block due to primary bradycardia. Signup and view all the answers

What are the signs and symptoms of tachyarrhythmias?

May cause nonspecific signs and symptoms that differ according to the child's age. Clinical findings may include palpitations, light-headedness, and syncope. Signup and view all the answers

Signs of hemodynamic instability associated with tachyarrhythmias?

Hypotension, altered mental status, signs of shock, sudden collapse with rapid weak pulses, respiratory distress or failure. Signup and view all the answers

How are tachycardia and tachyarrhythmias classified?

Based on the width of the QRS complex: narrow (0.09 seconds or less) vs wide (greater than 0.09 seconds). Signup and view all the answers

What is considered an initial management priority in managing tachyarrhythmias?

Obtain 12 lead ECG if possible, assess and support airway, oxygenation and ventilation. Signup and view all the answers

Signs and symptoms of ventricular tachycardia?

Wide QRS complex tachyarrhythmia generated within the ventricles, rapid ventricular rate compromising filing, stroke volume, and cardiac output. Signup and view all the answers

How many joules is needed for synchronized cardioversion?

Energy dose of 0.5 to 1 j/kg for cardioversion of SVT or VT with a pulse. Signup and view all the answers

What should be done with the defibrillator during VF/pVT?

Place defibrillator on patient and give 1 unsynchronized shock. Signup and view all the answers

Study Notes

Arrhythmias in Children

Assess arrhythmias for hemodynamic instability or signs of deterioration.
Signs of instability include respiratory distress, shock, irritability, decreased consciousness, chest pain in older children, and sudden collapse.

Management & Treatment Priorities

Initial management mirrors that for all critically ill children; support ABC and identify underlying causes.
Bradycardia is characterized by a slow heart rate for age, often due to tissue hypoxia.

Symptomatic Bradycardia

Symptomatic bradycardia occurs when heart rates drop below 60/min, associated with cardiopulmonary compromise, leading to hypotension and altered mental status.
Impending cardiac arrest in infants and children may present as bradycardia combined with hypotension.

Primary & Secondary Causes of Bradycardia

Primary bradycardia arises from congenital/acquired heart issues, such as pacemaker abnormalities, while secondary bradycardia is due to external factors like hypoxia, acidosis, or drug effects.

ECG Characteristics

Bradycardia on an ECG shows a slower heart rate, with P waves that may or may not be visible and QRS complexes that can be narrow or wide.

Atrioventricular Blocks

AV blocks disrupt electrical conduction; first-degree AV block shows prolonged PR intervals, while second-degree can be Mobitz type 1 or 2, varying in the number of conducted P waves.

Treatment Protocols

For pediatric bradycardia: initially, use bag-mask ventilation with 100% O2; if it persists, administer epinephrine.
Atropine accelerates heartbeat and enhances conduction and is preferred for bradycardia due to vagal tone or AV block.

Tachyarrhythmias Overview

Tachyarrhythmias are rapid rhythms from the atria or ventricles, potentially leading to hemodynamic instability with symptoms like hypotension or altered consciousness.
Narrow complex tachycardia includes sinus tachycardia and is typically triggered by physiological stress, while wide complex tachycardia can indicate ventricular issues.

Management of Tachyarrhythmias

Begin with obtaining a 12-lead ECG and support airway, oxygenation, and ventilation.
Synchronized cardioversion is used for atrial fibrillation and stable SVT; sedation is critical before the procedure.

Cardiac Arrest

Cardiac arrest results from ineffective heart activity, indicated by unresponsiveness and absence of normal breathing or pulse.
Recognize rhythms associated with cardiac arrest: asystole, PEA, V-Fib, and pulseless V-tach.

Post-Cardiac Arrest Care

Key steps post-arrest include treating organ dysfunction and ensuring optimal oxygenation, ventilation, and fluid balance.
Continuous monitoring and advanced life support are necessary to manage any life-threatening conditions present.

Medications and Dosage

Epinephrine is crucial for symptomatic bradycardia and should be given every 3-5 minutes.
For adenosine, administer an initial dose of 0.1 mg/kg, with a maximum second dose of 12 mg.

Special Considerations

Vagal maneuvers can help with SVT, and it is essential not to cover the nose/mouth during ice application for vagal maneuvers.
Confirmation of ET tube placement should be done using end-tidal CO2 monitoring.

Hemodynamic Compromise Factors

After resuscitation, understand that decreased cardiac function and inadequate intravascular volume can contribute to hemodynamic issues.

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Description

This quiz focuses on the assessment and management of arrhythmias in children, particularly bradycardia. It covers the signs of hemodynamic instability, treatment priorities, and the distinction between primary and secondary causes of bradycardia. Test your knowledge on the critical aspects of pediatric cardiac care.